Run DMHC!

Last week, on February 24, I got two emailed treats.

Jon Brooks from KQED, sent me a link to the Department of Managed Health Care’s just-released “Routine Survey Follow-up Report,” (a follow-up to the DMHC’s March 2013 report). He was curious about my comments which you can read in his article. Later that same day I got an email from Katie Gross, a staffer in US Senator Dianne Feinstein’s San Francisco office. Katie wanted to set up an immediate phone conversation to discuss my experience with Kaiser mental health. I spoke with her the next day, starting a conversation that I hope will end in a federal investigation into the Kaiser Advantage program. More on that in a bit.

But first, I offer a huge “thank you” to all to the folks at the DMHC who participated in the new report. By investigating follow-up services, (defined as any visit after an initial assessment), you’ve opened up a very large and slimy can of worms. Some may say that, considering the enormous pressure from consumers and therapists, you had no choice. But we all have our choices, including quitting our jobs if the going gets too rough. To those of you who stayed at your posts, thanks for going boldly. The report is five giant steps in the right direction.

The primary innovation in the DMHC’s follow-up report is a randomized medical record review. (A description of this review starts on page 18 of the report.) The DMHC hired a team of mental health professionals to review a random sampling of 300 notes charted between September 2012 and September 2013. This review yielded an estimate of how many mental health patients are underserved by the current system: 22% in Northern California and 9% in Southern California (from the report’s chart on page 19). I believe this is a serious underestimate of the problem, though I’m grateful for these numbers. The DMHC has finally started to assess and publicize the breadth of Kaiser’s negligence.

The chart review also produced clear evidence of the intransigence of Kaiser, the corporation, in the face of overwhelming evidence of the need to change. Witness this quotation from a Kaiser psychiatrist who emailed a patient: “’No one ever sees a therapist once a week in the Kaiser Health Plan. Not a covered benefit for the past 20 something years and will not be a benefit in the future.’” (From page 31.) This quotation is from a physician owner of The Permanente Medical Group, stating that no Kaiser member, not even someone with a parity mental health diagnosis, not even someone at grave risk for deterioration and suicide, no one gets weekly individual care from us. Furthermore, this psychiatrist taunts, this will never, ever change. (So quit asking.)

Sheesh!

It didn’t take a very large sampling of chart notes (300 charts reviewed) to reveal the corporate culture’s defiant stance toward parity laws. Nor did it take a large sample to reveal the breadth of the service gap resulting from physicians’ we’re-above-the-law position. Consider: “Case #B23: A sexual assault victim…diagnosed with post-traumatic stress disorder (PTSD) and major depression…. an appointment with a Plan therapist was scheduled five months after she was first seen.” (From page 31.) Or: “Case#R21: A child was brought in by her father due to the child’s aggressive behaviors, sexualized behaviors and significant behavioral problems in both the home and school environment… the child was not seen for therapy until seven weeks [after the initial assessment].” (On page 24.)

SO! The DMHC is starting to operationalize “timely care” in a manner that holds Kaiser more accountable. They’re also getting more precise about the health codes they’re citing to justify their increasing level of scrutiny. I wonder, along with you, what kind of fines will follow this report. (A separate arm of State government is responsible for levying the fines.) I wonder, too, if the fines will be suspended for a year or so, giving Kaiser the opportunity to restructure meaningfully. That’s what I would hope. A billion dollar fine, suspended, would possibly do the trick. This is a perfectly reasonable figure, since it will cost hundreds of millions of dollars in therapist salaries to approach the mandate of parity law. The fine must be greater than the cost of change to be effective at promoting change.

Now that the State has stepped up its game, it’s time for the Feds to follow suit, focusing on Medicare and Medicaid’s slice of the Kaiser membership pie.

For years, a significant portion of Kaiser members, including those with mental illness, have been funded by Medicare, under the Kaiser Advantage program. Since January 2014, the Affordable Care Act added another portion of publically-subsidized members to Kaiser, these funded by Medicaid (MediCal in California). Throughout, Kaiser has been given a complete pass on how they deliver mental health services under these entitlement programs. It’s been four years since Kaiser therapists published their white paper about the serious deficiencies in access to mental health care; and there has yet to be a comprehensive audit of Medicare’s mental health services.

Here’s what I am going to urge Senator Feinstein do, on behalf of federal taxpayers and Medicare and Medicaid recipients being denied mental health care on a daily basis. (1) Request that the Centers for Medicare and Medicaid Services (CMS) conduct an audit of mental health services delivered to Medicare and Medicaid recipients, and publish their results. And (2), sponsor an investigation into how Kaiser has, to this point, gotten away with defying federal parity laws.

I can only hope the Senator seizes this opportunity.